Government Health Care

Aaron Caroll:

There are plenty of things that government does poorly. Or, at least you can make that argument, and find some support for it out there. For instance, many people believe that government does a terrible job at sparking innovation. I could imagine a debate there. Some think that government does a bad job at providing choice. That’s entirely defensible. Government run systems also allow less room for profit, which can drive out entrepreneurs. Also arguable.

But what government systems do well is hold down costs. They use central planning. They use their large market power to negotiate for reduced reimbursement (see Part 2). They buy drugs cheaper. They eliminate profit and overhead.
 

 In a lot of ways this still understates the role of government in health care.  The regulatory rules about health care are aslo responsible for increasing prices as well and have some definite effects on innovation.  Now I happen to think that some of the rules are good (e.g. the FDA) and some of these rules are bonkers (e.g. limits on number of new physicians via residency slots).  But there is a point where you have to decide how you want a market to be run.  Designing it so that it regulates things that help interest groups (i.e. keeping physician numbers down) but not other things (i.e. reducing costs by using market power) is very much the definition of regulatory capture.

I am quite willing to have a discussion about free market health care.  The first barrier to a real free market system is how we deal with public health.  After all, it took government intervention to get sewers and outhouses to come into common use in Europe.  Just look at the complexity of the modern sanitation system in France.  There is a conflict between the freedom to dump waste on the streets and the need to protect the public from fecal borne disease.  Similar arguments can be made with the need to try and keep antibiotics effective. 

A system that keeps all of the regulatory barriers to entry but shifts costs to the consumer is a very partial form of opening an industry to the free market. 

Hearst and Hitler

In one of those synchronicity moments, shortly after writing this post about how the movie Citizen Kane plays with the persona of William Randolph Hearst, an unrelated news story got me to thinking about editors and publishers give platforms to people whom they would normally refuse to associate with. That got me thinking about how Hearst caught hell for some of those associations (and why this shot had such added significance for audiences back in 1941).

From a Newshour interview with Hearst biographer David Nasaw:

TERENCE SMITH: He had an odd relationship and view of both Adolf Hitler and Mussolini. Tell us about that.  

DAVID NASAW: Well, he had at one point working for him... because he had 20 million readers, he had a large number of politicians in the United States and world statesmen who wanted to write for him, who wanted to reach his audience. At one point or another in the 20s and the 30s, Winston Churchill, David Lloyd George, Benito Mussolini and Adolf Hitler all wrote for him. Hitler wrote for him from the time that his Nazi Party became the second-largest party in Germany until Hitler became the leader of the German state, at which point he demanded of Hearst that he be paid as much as Mussolini because he, too, was now a chief of state. Hearst denied him that request. Hearst said to the editor who was corresponding with Hitler, "Hitler doesn't write well enough, he doesn't meet his deadlines, he promises us exclusives he doesn't give us-- we don't need him." And they instead used Goering.

Levitt and publishing bias in medical journals

Via Andrew Gelman here is a quote from Steven Levitt

When I told my father that I was sending my work saying car seats are not that effective to medical journals, he laughed and said they would never publish it because of the result, no matter how well done the analysis was. (As is so often the case, he was right, and I eventually published it in an economics journal.)

Now compare his article to this one (published a year later):

OBJECTIVE: The objective of this study was to provide an updated estimate of the effectiveness of belt-positioning booster (BPB) seats compared with seat belts alone in reducing the risk for injury for children aged 4 to 8 years. METHODS: Data were collected from a longitudinal study of children who were involved in crashes in 16 states and the District of Columbia from December 1, 1998, to November 30, 2007, with data collected via insurance claims records and a validated telephone survey. The study sample included children who were aged 4 to 8 years, seated in the rear rows of the vehicle, and restrained by either a seat belt or a BPB seat. Multivariable logistic regression was used to determine the odds of injury for those in BPB seats versus those in seat belts. Effects of crash direction and booster seat type were also explored. RESULTS: Complete interview data were obtained on 7151 children in 6591 crashes representing an estimated 120646 children in 116503 crashes in the study population. The adjusted relative risk for injury to children in BPB seats compared with those in seat belts was 0.55. CONCLUSIONS: This study reconfirms previous reports that BPB seats reduce the risk for injury in children aged 4 through 8 years. On the basis of these analyses, parents, pediatricians, and health educators should continue to recommend as best practice the use of BPB seats once a child outgrows a harness-based child restraint until he or she is at least 8 years of age.

 So what is different?  Well, the complete interview data is a hint as to what could be happening differently.  It is very hard to publish a paper in medical journal using weaker data than that present elsewhere.  Even more interestingly, papers before this one found protective associations (this was 2006) which should also be concerning. 

Then we notice that the Doyle and Levitt has Elliott et al. as a reference, but still claim that they are the first to consider this issue:

This study provides the first analysis of the relative effectiveness of seat belts and child safety seats in preventing injury based on representative samples of police-reported crash data.

So now let us consider reasons that a medical journal may have had issues with this paper.  First, it does not seem to deal with the previous literature well.  Second, it doesn't explain why crash testing results do not seem to translate into actual reduction in events.  It might be due to misuse of the equipment, but it is not clear to me what the conclusion should be then. 

But it seems that jumping to the conclusion that the paper would not be published because of the conclusion seems to assume facts not in evidence.  It is common for people to jump fields and apply the tools that they have learned in their discipline (economics) and not necessarily think about the issues that obsess people in the field (public health).  Some times this can be a good thing and a new perspective can be a breath of fresh air.  But in a mature field it can also be the case that there is a good reason that the current researchers focus on the points that they do.

This reminds me of Emily Oster, another economist who wandered into public health and seemed surprised at the resistance than she encountered.

So is the explanation Levitt's father gave possible?  Yes.  But far more likely was the difficulty of jumping into a field with a high counter-intuitive claim and hoping for an immediate high impact publication.  Medical journals are used to seeing experiments (randomized controlled drug trials, for example) overturn otherwise compelling observational data.  So it isn't a mystery why the paper had trouble with reviewers and it does not require any conspiracy theories about public health researchers not being open to new ideas or to data. 

Cost is tricky in health care

An interesting Yglesias post:

Instead the existing Medicare Advantage program tries to apply a risk-adjustment formula to the patients, and Ryan proposes doing the same in his greatly expanded version of Medicare contracting-out. But this doesn't change the fact that the real profit-making opportunity here is to try to identify and exploit inevitable flaws in the risk-adjustment process. The winning strategy is to craft products that are appealing to customers the formula is willing to overpay for and unappealing to customers the formula would underpay for. Now that could be a small problem or a it could be a giant problem, all depending on how good the government is at setting the rates. Which is to say that for bringing private bidders into the process to work well, you need really effective central planning. And to the extent that you have effective central planning, it seems to me that it makes sense to take advantage of the economies of scale that come from a single-payer system.

I think that this understates just how tremendously difficult epidemiological risk modeling really is.   But I do not think it undermines the central point -- once you put the work into risk adjusting the payouts to private companies you have all of the machinery for a single payer approach.  And it is dead obvious why a naive approach won't work.  But even the modern risk models aren't that great accoridng to Peter Orszag:

In 2006, Medicare Advantage plans were overpaid by more than $3,000 per beneficiary because they were able to select beneficiaries who cost less than their risk-adjusted payments. About $1,000 of that overpayment reflects what the plans were paid, rather than what they bid. So relative to their bids, the plans were overpaid by $2,000 per beneficiary -- or roughly 25 percent of the bid, on average.

That is a huge profit making potential (just think of the return on investment for that statistical model).  So you focus the incentives of the private sector on finding weak spots in the model (because that is incredibly profitable) and not on reducing health care costs (because that is hard and painful). 

I am somewhat sympathetic to the "put lot's of resources in medicine and technological improvements will follow" types of arguments.  But it seems to me that this approach is going to focus the innovation in precisely the wrong spot. 

Ground source heat pumps

Some background for an upcoming post.

From Wikipedia:

The US Environmental Protection Agency (EPA) has called ground source heat pumps the most energy-efficient, environmentally clean, and cost-effective space conditioning systems available. Heat pumps offer significant emission reductions potential, particularly where they are used for both heating and cooling and where the electricity is produced from renewable resources.
...
Ground source heat pumps are characterized by high capital costs and low operational costs compared to other HVAC systems. Their overall economic benefit depends primarily on the relative costs of electricity and fuels, which are highly variable over time and across the world. Based on recent prices, ground-source heat pumps currently have lower operational costs than any other conventional heating source almost everywhere in the world. Natural gas is the only fuel with competitive operational costs, and only in a handful of countries where it is exceptionally cheap, or where electricity is exceptionally expensive. In general, a homeowner may save anywhere from 20% to 60% annually on utilities by switching from an ordinary system to a ground-source system. However, many family size installations are reported to use much more electricity than their owners had expected from advertisements. This is often partly due to bad design or installation: Heat exchange capacity with groundwater is often too small, heating pipes in house floors are often too thin and too few, or heated floors are covered with wooden panels or carpets.
...
Capital costs may be offset by government subsidies, for example, Ontario offered $7000 for residential systems installed in the 2009 fiscal year. Some electric companies offer special rates to customers who install a ground-source heat pump for heating or cooling their building. Where electrical plants have larger loads during summer months and idle capacity in the winter, this increases electrical sales during the winter months. Heat pumps also lower the load peak during the summer due to the increased efficiency of heat pumps, thereby avoiding costly construction of new power plants. For the same reasons, other utility companies have started to pay for the installation of ground-source heat pumps at customer residences. They lease the systems to their customers for a monthly fee, at a net overall savings to the customer.

Medical Costs

A very left wing blogger writes:

Saying that voucherizing Medicare merely wouldn’t “hold down costs” is far too charitable. In fact, the evidence is unambiguous that voucherizing Medicare would increase costs all things being equal, since private insurers are clearly less efficient than actually existing Medicare.

It is worth noting that countries with public medical systems seem to get similar health outcomes at much lower costs.  I am unclear why "privatizing" of medical care is limited to shifting the costs to patients instead of a single payer.  Why does it not tackle licensing issues that result in a medical doctor shortage (which raises wages and thus costs)?  Or open up prescribing powers to more providers (why can Pharmacists not prescribe?)?

It seems to be odd to focus on this one aspect of the health care segment of the economy and not even discuss the other regulatory issues involved.

Some thoughts on cinema overe at MippyvilleTV

Arrested (cinematic) Development

With friends like these.. Peter Bogdanovich and Citizen Kane

More Econ 101

Worth pondering

So, when somebody says that the government should buy paper from a private provider, hey, great. There are lots of buyers and sellers of paper. Go for it. If somebody wants to contract out janitorial work or food service, again, there are lots of buyers and sellers of those services. But I’ve never seen how contracting out more specifically governmental tasks really improves things. You go from having a monopoly provider, with all the disadvantages thereof, to a monopsony buyer, that still has to exert oversight (which is subject to all sorts of information problems and all sorts of good and bad incentives). And if there’s only one buyer, that buyer is, effectively, a monopoly provider for the public.

In all sorts of arenas, information is the real limiting factor.  I like to apply this to fields like health care.  There is no real open market in health care.  We have subsidized insurance or government provided insurance for the majority of customers.  The plans that exist often lock in networks that make it more challenging to comparison shop.  Most customers do not have the ability to shop around on price.  Treatments are legally protected from being sold on the open market (you can't self treat with a statin).  Medical doctors are a protected guild that has a limited number of residencies (and thus a cap on members) leading to increased costs due to shortages. 

None of this looks like a functional market with good information, equal quality goods, freedom of entry/exit, or substitution effects on treatment. 

Worth pondering. 

One hundred degrees by moonlight

When you add up all of the associated costs of global warming, I don't see how a good cost benefit analysis could possibly support doing nothing.

From All Things Considered:

Phoenix actually suffers from two heat problems. One is a product of growth. Desert nights don't cool down they way they used to, because energy from the sun is trapped in roads and buildings, a phenomenon researchers call the "urban heat island effect."

As Phoenix grows, so does the problem, says Nancy Selover, the state climatologist.

"We keep thinking we'll probably see a night when we only get down to 100 as a minimum temperature, which is kind of shocking," Selover says.

Stock Markets

Brad Delong

Historically, people who invest in indexed mutual funds like the Vanguard S&P make 5.5%/year above inflation (but, alas! only 1%/year since January 1, 2000); people who invest in actively-managed mutual funds like those run by Fidelity make 4.5%/year above inflation (but, alas! only 0%/year since January 1, 2000); people who actively trade individual stocks turning over their portfolio once year or so as it appears Paul Ryan does make 3.5%/year above inflation (but, alas! only -1%/year since January 1, 2000); and day-traders who trade every day lose 5%/year (and, alas! have lost 10%/year since January 1, 2000).

These differences in returns are a lot of the reason that I see it as critical to have a paternalist view on retirement savings.  The more involved the individual invester is, the worse that they seem to do in the brave new world of finance.  Passive investing, the best option listed, depends critically on individual stocks not going out of balance with the whole (ask any Canadian about Nortal and Canadian stock index funds).  But all of the other options are worse. 

If the more recent (since 2000) figures are the result of demographic factors and not as a result of "unique" or "unlikely" economic factors (due to the liquidity crisis or what not) then the future of stock market investment is bleak indeed.  At the very least, periods of slow growth like this are not good signs for the future. 

Not sure about the message here

I just saw this ad. a few moments ago. I suppose it's a good sign that the Romney team got the updated ads out this quickly, but "Comeback Team" may not be the ideal slogan. It could be read as :the team to lead America's comeback." That's OK but it's not the first reading that comes to mind. 

When I see the phrase  "Comeback Team," I normally think "sure, we're behind but don't count us out." That may be a realistic message but I don't think it's one the campaign wants to push.

What's a winning strategy for a lottery (and what does winning really mean)?

Two interesting stories on lotteries, one recent, the other old but still relevant.

The first, from Felix Salmon, tells of a type of lottery with a positive expected value if you bought your tickets at the right time :

Because the jackpot was basically never won, it couldn’t just keep on rising indefinitely. So Cash WinFall had a mechanism for distributing it: when the jackpot rose above $2 million, it would “roll down” into smaller prizes. For instance, if you got five out of six numbers correct in a normal week, you would win $4,000; in a roll-down week, you would win $40,000.

A bunch of what can only be called professional lottery players jumped on this quirk, and would buy up hundreds of thousands of dollars’ worth of tickets in roll-down weeks, when the swollen jackpot was certain to get distributed. By buying so many tickets, they pretty much guaranteed that they would buy enough winning tickets to turn a profit — in a typical roll-down week, they would win back 15% to 20% more than they gambled.

Weirdly, the big risk here was the 1.4% chance that the jackpot would be won — as happened, for instance, on July 10, 2008. That worked out very well for the winner, Wenxu Tong, the general partner of a company called Tong’s Fortunelot Limited Partnership, who took home nearly $2.5 million. But all the other consortiums trying to game the system that week all did very badly, losing hundreds of thousands of dollars.

There was a tinge of scandal to Estes’s reporting. “Cash WinFall isn’t being played as a game of chance,” she quoted Mohan Srivastava as saying. “Some smart people have figured out how to get rich while everyone else funds their winnings.’’ And a few days after her story appeared, the Boston Globe ran an editorial under the headline “Lottery game is fatally flawed; treasurer should shut it down”. The argument? In any lottery game, according to the paper, “the odds should be stacked equally against rich and poor”. And eventually, earlier this year, Cash WinFall was indeed phased out.

Now Gregory Sullivan, the state inspector general, has written a 25-page report on the Cash WinFall game, which is well worth reading; Estes, naturally, has written it up for the Globe, under the headline “Lottery officials knew about Cash WinFall’s flaws, IG says”. She never mentions, however, the report’s conclusion: those “flaws” ended up being very profitable for the state, and were a way for Massachusetts to get significant lottery revenues not only from the poor but also from the rich.

The second, from This American Life back in 2007, looks at the impact of winning a lottery as reported by a man whose job it was to buy those jackpots for a lump sum payment:

What Ed found was that, if lottery winners felt like they could relate to him, could trust him, then they'd be much more willing to do the deal, no matter what the terms. And Ed found it wasn't hard to get them comfortable because they actually had a lot in common.


Ed Ugel: It was just a natural fit for me. One of the biggest things that helped me was my intimate understanding of the mind of a gambler.

A fellow I did a deal with in Florida, we went to a notary to get certain pages of the contracts, all the contracts needed to be signed. Some of the signature pages needed to be notarized. And this notary happened to also sell lottery tickets. And when we went and got these pages notarized, he whipped out a wad of bills out of his pocket and bought 1,000 scratch tickets while the notary slash lottery ticket salesperson was notarizing the signature pages on his contract to sell me his annuity from the lottery win. He was sitting there. He didn't even look at the contracts. He's just scratching away. He couldn't even wait to get away from the booth. I'll never forget the way the notary looked at me sort of in awe. And yeah, it was a little daunting, a little bizarre seeing it. But I knew just who this cat was. I'd been that guy. And I would like to think that maybe I was a little bit better than scratch tickets in the airport, but I don't know that scratch tickets in the airport are that much classier than video poker machines in the strip clubs of Oregon.

Is there a political historian in the house?

It seems unusual to announce a VP pick more than two weeks before the convention. How common is this sort of thing?

My problems with Matt Yglesias' Slate piece

Joseph recently had a post on Matt Yglesias's Slate piece on data. I pointed out in the comments that I wasn't that impressed. Here's a more detailed explanation.

I realize that Yglesias is writing for a general audience and that can muddle the issue, but I keep getting the feeling that he really doesn't get the subtlety here, that he misses the fundamental asymmetry between significance and insignificance and the importance of what Friedman and Rowe are saying.

I don't want to get caught up in the weeds of interpreting (let alone defending) p-value, but if you see a contextually significant result you pretty much know that there's a relationship there. It may not be causal or useful and it may not be what it appears, but there's something.

If you don't see a significant result, you don't know anything. Maybe there's nothing there or maybe there's too much noise or the relationship is outside the range of data or you could be using techniques that miss nonlinear relationships (an argument for CHAID and CART but that's a topic for another post). You certainly wouldn't draw a conclusion like burning fossil fuels doesn't cause heat.

As for the thermostat scenario, Yglesias focuses on this as an example of observational analysis missing a relationship. That's true but it's a very specialized case of a wide spread problem (lots of things cause us to miss relationships). Furthermore, it misses the real profundity of the analogy: it is the job of self-regulating systems to put forces in opposition, to set up destructive interference. The better the system works, the less appears to happen.

And finally, while I'm in a picky mood,  Yglesias should realize that lots of natural sciences (astronomy, meteorology) make very limited use of experiments.

Two essential posts on the Ryan pick

Nate Silver looks at the electoral implications.

Jonathan Chait handles the historical context.